Clinical Practice Guidelines
UnitedHealthcare Community and State recommends the following non-preventive clinical practice guidelines to help practitioners and members make decisions about appropriate health care for specific clinical circumstances.
ASTHMA
2007 National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Diagnosis and Management of Asthma
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
Global Initiative for Asthma, Pocket Guide for Asthma Management and Prevention. A Pocket Guide for Physicians and Nurses Updated 2010 http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=37
COPD
Chronic Obstructive Pulmonary Disease
2010 Global Initiative for Chronic Obstructive Lung Disease
http://www.goldcopd.com/
CAD
AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update. Endorsed by the National Heart, Lung, and Blood Institute. Sidney C. Smith, Jr, MD, et. al.
http://content.onlinejacc.org/cgi/reprint/47/10/2130.pdf
2007 Evidenced-based Guidelines for Cardiovascular Disease Prevention in Women
http://circ.ahajournals.org/cgi/reprint/115/11/1481
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update
A Guideline From the American Heart Association. Executive Writing Committee
Lori Mosca, MD, MPH, PhD, FAHA, Chair, et. al.
http://circ.ahajournals.org/cgi/reprint/CIR.0b013e31820faaf8v2.pdf
HEART FAILURE
2009 Focused Update Incorporated Into the ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation.
Sharon Ann Hunt, MD, FACC, FAHA, Chair, 2005 Writing Committee Member, et al.
http://content.onlinejacc.org/cgi/reprint/j.jacc.2008.11.013v1.pdf
DIABETES
Standards of Medical Care in Diabetes – 2011.
Position Statement, Summary of Revisions and Executive Summary. Diabetes Care January 2011 34:S11-S61; doi:10.2337/dc11-S011 http://care.diabetesjournals.org/content/34/Supplement_1
MATERNITY MANAGEMENT (Healthy First Steps)
American College of Obstetrics and Gynecology, American Academy of Pediatrics. Guidelines for Perinatal Care, Sixth Edition. 2010
http://www.acog.org/publications/educational
Evidence- Based Prenatal Care: Part I. General Prenatal Care and Counseling Issues. American Family Physician. 2005 Apr 1; 71(7):1264, 1266. Kirkham, C., Harris, S., & Grzybowski, S.
http://www.aafp.org/afp/20050401/1307.html
Revised Recommendations for HIV Screening of Pregnant Women. Prepared by
Bernard M. Branson, MD, et. al. MMWR. September 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
OBESITY (Weight Management)
Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Sarah E. Barlow and the Expert Committee. Pediatrics 2007; 120; S164-S192 DOI: 10.1542/peds.2007-2329C
http://www.pediatrics.org/cgi/content/full/120/Supplement_4/S164
The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 2000. The National Institutes of Health, the National Heart, Lung, and Blood Institute, and the North American Association for the Study of Obesity. NIH Publication Number 00-4084. (Update in development)
http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
BIPOLAR
American Psychiatric Association Best Practice Guideline + Resources for: Treatment of Patients with Bipolar Disorder, Second Edition. November 2002.
http://www.psychiatryonline.com/pracGuide/pracGuideTopic_8.aspx
DEPRESSION
American Psychiatric Association Practice Guideline + Resources for: Treatment of Patients with Major Depressive Disorder, Third Edition. November, 2010
http://www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx
SCHIZOPHRENIA
American Psychiatric Association Practice Guideline + Resources for: Treatment of Patients with Schizophrenia, Second Edition. April, 2004 http://www.psychiatryonline.com/pracGuide/pracGuideTopic_6.aspx
United Healthcare Community and State also recommends the following preventive clinical practice guidelines to help practitioners and members make decisions about appropriate health care regarding preventive services.
PREVENTIVE SERVICES
Agency for Healthcare Research and Quality and the U.S. Preventive Services Task Force's Recommendations.
http://www.uspreventiveservicestaskforce.org/recommendations.htm
Department of Health and Human Services • Centers for Disease Control and Prevention.
2011 Recommended Adult Immunization Schedule
http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf
Department of Health and Human Services • Centers for Disease Control and Prevention. CDC 2011 Recommended Immunization Schedule for Persons Aged 0 - 6 Years
http://www.cdc.gov/vaccines/recs/schedules/downloads/child/0-6yrs-schedule-pr.pdf
Department of Health and Human Services • Centers for Disease Control and Prevention. CDC 2011 Recommended Immunization Schedule for Persons Aged 7 - 18 Years
http://www.cdc.gov/vaccines/recs/schedules/downloads/child/7-18yrs-schedule-pr.pdf
UTILIZATION GUIDELINES
Utilization Guidelines, such as Milliman Utilization Care Guidelines, may be used as part of the prior authorization process. You may request a copy of a specific guideline by calling 1-888 650-3462.
Topic |
Guideline |
|
Acute Myocardial Infarction (MI) |
2009 Focused Updates: Acc/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update) Source: American College of Cardiology/AHA: http://circ.ahajournals.org/content/120/22/2271.full.pdf |
| Acute Myocardial Infarction without ST Elevation | 2011 Focused Update: ACC/AHA Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline). Source: American College of Cardiology/AHA: http://circ.ahajournals.org/content/123/18/e426.full.pdf+html |
| Asthma | 2007 National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Diagnosis and Management of Asthma. Source: National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm |
| Attention Deficit Hyperactivity Disorder (ADHD) | 2007 Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit Hyperactivity Disorder. Source: American Academy of Child and Adolescent Psychiatry: http://dss.mo.gov/mhd/cs/psych/pdf/jaacap_adhd2007.pdf |
| Bariatric Surgery | Bariatric Resource Service Clinical Job Aids: • Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD- DS) • Laparoscopic Roux-en-Y Gastric Bypass Procedure (LRYGBP) • Laparoscopic Sleeve Gastrectomy (LSG) • Laparoscopic Adjustable Gastric Banding (LAGB) |
|
Bipolar Disorder: Adults |
Guideline Watch (November 2005): Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd Edition. |
|
Bipolar Disorder: Children & Adolescents |
Guideline Watch (November 2005): Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd Edition |
|
Cardiology: CareCore ENM Guidelines |
Physician Guidelines: Current Evidence-Based Recommendations Regarding Cardiology (2012). |
|
Cardiovascular Disease: Prevention in Women |
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update: A Guideline from the American Heart Association. Source: American Heart Association: http://circ.ahajournals.org/content/123/11/1243.full.pdf |
Cardiovascular Disease: Secondary Prevention |
|
Cervical Cancer Screening |
|
|
Chemotherapy Observation or Inpatient Hospitalization |
UHC Utilization Review Guidelines – Chemotherapy Observation or Inpatient Hospitalization. |
|
Cholesterol Management
|
2004 Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults(Adult Treatment Panel III). Source: National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm |
Chronic Obstructive Lung Disease |
2011 Global Initiative for Chronic Obstructive Lung Disease. |
|
Chronic Stable Angina |
2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients with Chronic Stable Angina. Source: American College of Cardiology/AHA: http://circ.ahajournals.org/content/116/23/2762.full |
|
Depression/Major Depressive Disorder |
Practice Guideline For The Treatment of Patients With Major Depressive Disorder, Third Edition. Source: American Psychiatric Association: http://psychiatryonline.org/guidelines.aspx |
| Diabetes |
Standards of Medical Care in Diabetes - 2012. |
| External Insulin Infusion Pump During Pregnancy |
Healthy First Step: External Insulin Subcutaneous Infusion Pump for Diabetes in Pregnancy. Source: Community and State Medical Necessity Prior Authorization Criteria Job Aid. |
| Heart Failure |
2009 Focused Update Incorporated Into the ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Heart Failure in Adults. Source: American College of Cardiology/American Heart Association: http://circ.ahajournals.org/content/119/14/e391.full.pdf |
Hemophilia and von Willebrand Disease |
Guidelines for the Management of Hemophilia. |
|
|
Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America. |
Hyperbili-rubinemia in Newborns |
American Academy of Pediatrics Clinical Practice Guideline (2004): Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. American Academy of Pediatrics (2009): Hyperbilirubinemia in the Newborn Infant ≥35 Weeks’ Gestation: An Update with Clarifications. Source: American Academy of Pediatrics: http://pediatrics.aappublications.org/content/124/4/1193.full.pdf |
| Hypertension | The Seventh Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (2004). Source: National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf |
| Infertility | • Fertility Preservation Clinical Guidelines • ICSI Clinical Guidelines • Natural Cycle Clinical Guidelines • Ovarian Stimulation Clinical Guideline • PCOS Clinical Guidelines • Single Embryo Transfer Clinical Guidelines • Standard Infertility Workup Clinical Guidelines • Treatment of Unexplained Infertility Clinical Guidelines |
Inpatient Pediatric Feeding Programs |
UHC Utilization Review Guidelines – Inpatient Pediatric Feeding Programs. Source: (UnitedHealthcareOnline.com): https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Inpatient%20Pediatric%20Feeding%20Programs_URG.pdf |
|
Maternal Support Program Clinical Guidelines |
• Anemia and Pregnancy Clinical Guidelines • Cervical Insufficiency Clinical Guidelines • Avoidance of Elective Deliveries before 39 Weeks Gestation • Assessment of Fetal Well Being • Administration of 17P for Prevention of Preterm Birth • Breast Milk Feeding • Coagulation Disorders in Pregnancy • Gastrointestinal Disease in Pregnancy • Gestational Diabetes • Intrauterine Growth Restriction (IUGR) • Malignancy and Pregnancy • Maternal and Fetal Infections • Maternal Nutrition and Obesity • Multiple Gestation • Placenta Previa • Diseases of the Liver Biliary System and Pancreas in Pregnancy • Post-Term Pregnancy • Pregnancy Related Hypertension • Premature Rupture of Membranes (PROM) • Preterm Labor and Birth • Respiratory Disease in Pregnancy • Thromboembolic Disease in Pregnancy • Thyroid Disease in Pregnancy • Trial of Labor after C-Section (TOLAC) and Vaginal Birth after C-Section (VBAC) |
| Milliman Care Guidelines | Milliman Care Guidelines®, 17th Edition. Source: Milliman Care Guidelines: http://www.careguidelines.com |
| Oncology |
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in OncologY.
|
|
Organ Transplantation (Optum Health) |
UHC 2011Transplant Review Guidelines: Solid Organ and Stem Cell Transplantation. Source: (UnitedHealthcareOnline.com): https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Clinical%20Guidelines/Transplant_Review_Guidelines.pdf |
|
Perinatal Care |
American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Sixth Edition, Guidelines for Perinatal Care. |
| Preventive Pediatric Health Care Screening | 2009 Recommendations for Preventive Pediatric Health Care: American Academy of Pediatrics Screening Guidelines (periodicity schedule). Source: American Academy of Pediatrics: http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf |
|
Preventive Services |
Guide to Clinical Preventive Services, 2010-2011: Recommendations of the U.S. Preventive Services Task Force Note: Although the USPSTF concluded that the current evidence is insufficient to assess the additional benefits and harms of digital mammography instead of film as a screening modality for breast cancer, before the age of 50, UnitedHealthcare will cover this as a preventive health service. Source: Agency for Healthcare Research and Quality: http://www.ahrq.gov/clinic/pocketgd.htm |
|
|
Physician Guidelines: Current Evidence-Based Recommendations Regarding Imaging (2012). Source: (Unitedhealthcareonline.com): https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/Radiology%20Notification%20Program/Evidence_Based_Clinical_Guidelines-Imaging_2012.pdf |
| Schizophrenia | Guideline Watch (September 2009): Practice Guideline for the Treatment of Patients with Schizophrenia. Source: American Psychiatric Association/ PsychiatryOnline Guideline Watch: http://psychiatryonline.org/content.aspx?bookid=28§ionid=1682213#501001 |
Sickle Cell Disease |
The Management of Sickle Cell Disease, 4th Edition National Heart, Lung, and Blood Institute (NHLBI). Source: National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov/health/prof/blood/sickle/sc_mngt.pdf |
| Spinal Stenosis | 2011 Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. Source: North American Spine Society: http://www.spine.org/Documents/LumbarStenosis11.pdf |
| Substance Use Disorders | Guideline Watch (April 2007): Practice Guideline for the Treatment of Patients with Substance Use Disorders. Source: American Psychiatric Association/ PsychiatryOnline Guideline Watch: http://focus.psychiatryonline.org/article.aspx?articleid=52296 |